Conflict of Interest Disclosure Statement

Volunteers on behalf of the American Society of Echocardiography (ASE) have a fiduciary duty to ASE, including the duties of loyalty, diligence and confidentiality. Despite the self-interests that members inevitably have, those in positions of responsibility, in their fiduciary capacity, must act in utmost good faith on behalf of ASE. In accepting their positions, they undertake to give the association the benefit of their care and best judgment and to act solely in the interest of the association and not for their own personal interest.

Conflicts of interest arise when participants in positions of responsibility have personal or outside financial, business or professional interests or responsibilities that conflict with their duties to ASE. The immediacy and seriousness of various conflicts of interest situations can differ. Of significant importance is the degree to which an actual or potential conflict would tend one toward bias in educational matters, pre-disposition on any issue affecting the Society or its members or otherwise compromise the interests of the Society in any way.

A conditional, qualified or potential conflict of interest can arise when the outside interest does not relate to any contemplated action of ASE. For example, a person might hold a minor financial stake in a non-commercial company wishing to do business with the Society. Disclosure is ordinarily sufficient to deal with this type of conflict, provided that there is no reasonable belief that one’s decisions could be biased or one’s duty of loyalty to ASE affected.

A direct conflict of interest arises when an individual holds a position of responsibility with the ASE and also holds a material interest in the issues charged to the volunteer or elected position at hand. Direct conflicts of interest arise when an individual engages in a personal transaction with the Society, holds a material interest or position of responsibility in an organization involved in a specific transaction with the ASE, or whose loyalties lie in equal measure with a commercial entity. Such situations place the person in the impossible position of attempting to represent both the ASE and one’s personal interests or those of the other organization. The mandatory course of action in such cases is to disclose the conflict and remove oneself from the deliberations and the vote on the issue. Should the ASE feel that one’s conflicts of interest cannot be resolved to maintain the goals or integrity of the position, ASE will revoke invitation to participate or reassign such individuals to an alternate position where the identified conflicts will have no bearing on any voting matters.

In rare circumstances, an individual currently seated in a voluntary or elected position may have such a serious, ongoing and irreconcilable conflict, where the relationship to an outside organization so seriously impedes one’s ability to carry out the fiduciary responsibility to the ASE, that resignation from the position with ASE or the conflicting entity is mandatory.

Dealing effectively with actual or potential conflicts of interest is a shared responsibility of the individual (disclosure) and the organization (resolution). Accordingly, ASE requires the completion of a ‘Conflict of Interest Disclosure Statement’ by members of each Committee, Task Force and Council. The Society reviews each Conflict of Interest Disclosure Statement individually. ASE officers and members of the Board, Committees and Task Forces must file annual signed statements with the executive office of the Society. Statements are also required at the time of appointment to a Board, Committee or Task Force. This information will be retained in the files of the ASE office and may be shared with members of ASE’s leadership, staff and other individuals as necessary.Modified/Appproved March 2012

First Name

Last Name

Institution to be Included in the Document Author Listing

Medical Degrees and Credentials

Business Address:

City, State, Country

Describe any additional volunteer positions you hold, including a brief description of the nature and purposes of the organization(s).

Describe any outside relationships that you may hold with any person or organization:
a. from which ASE obtains substantial amounts of goods and services,(e.g. a vendor which ASE uses for its printing or publishing services), or
b. which provide products or services that substantially compete with ASE (e.g. CME products that compete with ASE CME products).

Describe any substantial financial interests or positions of responsibility that you may have in non-commercial organizations that provide goods, products, or services in support of the practice of echocardiography (e.g. billing company, staffing or recruitment

Describe any relationship you have with a commercial interest. A commercial interest is defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients, with the exception of non-profit or government organizations and non-health care related companies. Providers of clinical services directly to patients are not considered a commercial interest. Relationships in any amount should be disclosed and can include, but are not limited to: 1) Receiving grants or research support; 2) Stockholder (You do not need to include diversified mutual funds); 3) Member of speakers' bureau; 4) Consultant or member of a scientific advisory committee; 5) Officer, board member, trustee, or employee*

*Those individuals seeking assignment to the Board of Directors or education-based committee or task force (e.g., Scientific Sessions Program Committee, Education Committee, Products Task Force, etc), are prohibited from having been an employee of a commercial interest within the last 12 months. An employee is defined as one who has a regular work schedule and receives a regular paycheck. Self-employed individuals who contract with a commercial firm are not considered employees; however, these types of relationships must be reviewed in detail by ASE and participation on any committee as named above will be at the discretion of appropriate ASE leadership.

Have you been an employee of a commercial interest within the last 12 months?

YesNo

Describe any other interest, including any outside or financial relationships of your spouse/significant other, that may create a conflict with the fiduciary duty to the membership of ASE or that may create the appearance of a conflict of interest.

The Accreditation Council for Continuing Medical Education (ACCME) requires the American Society of Echocardiography (ASE) to identify and resolve conflicts of interest for all individuals responsible for the development, management, presentation and/or evaluation of a CME/CE activity. In order to fulfill this requirement, ASE can only approve a CME/CE activity when all individuals involved in the educational process have completed the following content control agreement:

I understand that the information presented in all activities must be unbiased, scientifically balanced, and based on best
available evidence and best practices in medicine. I agree to consider all reasonable clinical alternatives when selecting or
reviewing content. I attest that relationships with commercial interests will not influence or bias my involvement and/or
planning of the CME activity.YesNo

All scientific research referred to, reported, or used in support or justification of patient care recommendations will conform
to the generally accepted standards of experimental design, data collection, and analysis.YesNo

I attest that I will not accept any payment or reimbursement for any educational activity from any commercial interest.
I understand that all reimbursements (when applicable) must be made by the ASE.YesNo

I agree to notify ASE CME staff within 30 days of acquiring or cancelling any relationship with a commercial interest.YesNo

I have read ASE’s policy on Conflict of Interest and Disclosures and support its intent. I agree to:
a. Acknowledge my responsibility to the ASE and agree to avoid conflicts of interest or the appearance of conflicts of interest;
b. Acknowledge that at times I may have access to confidential information and agree to protect the confidentiality of that information;
c. Disqualify myself and absent myself from participating in any association matters which are a conflict of interest; and
d. Update this form as needed to keep it current and accurate.